Provider Demographics
NPI:1851407761
Name:SULLIVAN, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7555 E MERCED FALLS RD
Mailing Address - Street 2:
Mailing Address - City:SNELLING
Mailing Address - State:CA
Mailing Address - Zip Code:95369-9733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:378 W OLIVE AVE
Practice Address - Street 2:# C
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348
Practice Address - Country:US
Practice Address - Phone:209-726-0944
Practice Address - Fax:209-726-1001
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22668208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A226680Medicaid
CA00A226680Medicare ID - Type Unspecified
A23200Medicare UPIN